Extended daclizumab monotherapy for rejection‐free survival in non‐adherent adolescent recipients of renal allografts

  Acute rejection episodes are almost inevitable in the face of immunosuppression non‐adherence and a known risk factor for developing chronic allograft nephropathy and accelerated graft loss. Daclizumab, a humanized monoclonal antibody directed against the alpha chain of the IL‐2 receptor, is an important advance for induction therapy in renal transplant immunosuppression, reducing early acute graft rejection without affecting the tolerability of standard immunosuppression, for both steroid‐based and steroid‐free immunosuppressive protocols, in children and adults. In the absence of depot immunosuppression for maintenance therapy, we explored extended daclizumab therapy as temporary maintenance immunosuppression for acute rejection prophylaxis in two patients with recalcitrant immunosuppression non‐adherence. Both patients had prior episodes of aggressive acute rejection associated with their non‐adherence but achieved stable and rejection‐free renal allograft function with daclizumab monotherapy in the presence of documented non‐adherence thus providing an effective bridge for up to 12 months until immunosuppression adherence was re‐established with ongoing psychosocial support. This report suggests that daclizumab monotherapy over an extended period of time during the period of non‐adherence in the post transplant period could be a rescue modality to avoid immune activation and thereby prevent acute rejection in the face of erratic maintenance immunosuppression.